Anatomic Fashion Research Articles

Carpometacarpal Ligament Reconstruction, Surgical Technique and Outcomes.

Basal thumb arthritis is a common condition with the earliest stage described as a period of ligament laxity and joint instability, without radiographic signs of arthritis. The condition is usually managed conservatively but a number of individuals can present with persistence of symptoms. We would like to describe our preferred technique for the management carpometacarpal ligament instability and laxity. This technique utilizes a slip of the flexor carpi radialis tendon and offers reconstruction of the intermetacarpal, dorsoradial and anterior oblique ligaments in an anatomic fashion using standard instruments available. The author has performed this technique in 33 patients over a course of 10 years and long-term outcomes of these cases are presented in this paper.

Posterolateral Corner Reconstruction

Background: Anatomic posterolateral corner (PLC) reconstruction is utilized for ligamentous knee instability associated with PLC injury in patients who desire a return to active lifestyles 1,2 . The fibular collateral ligament (FCL) and popliteal tendon (PLT) are reconstructed in anatomic fashion according to techniques described by LaPrade et al. 3–7 . Description: Various PLC reconstruction techniques have been described; however, the preferred reconstruction technique of the senior author is the method developed by LaPrade et al. that restores the anatomy of the 3 primary stabilizers of the PLC, including the FCL, PLT, and popliteofibular ligament 3,5,6 . Alternatives: Alternative nonoperative treatments include knee immobilization for 4 weeks and physical therapy. Surgical alternatives include PLC repair, which involves repair of the lateral collateral ligament, PLT, and/or popliteofibular ligament if structures can be anatomically reduced to their attachment site. However, repair of acute grade-III PLC injuries with staged treatment of concurrent cruciate injuries is associated with a substantially higher postoperative PLC failure rate 8–10 . Rationale: Clinical outcomes have demonstrated that primary repairs have significantly higher rates of reoperation compared with reconstruction; therefore, reconstruction is recommended. Treatment of grade-III PLC injuries with reconstruction of midsubstance tears and any associated cruciate ligament tears results in significantly improved objective stability 11 . In addition, anatomic PLC reconstruction has demonstrated improved subjective and objective patient outcomes compared with nonsurgical treatment or repair 5,11,12 . Expected Outcomes: Reconstruction of the PLC offers excellent outcomes after surgery. Studies have shown that the fibular-based technique for treatment of a chronic isolated PLC injury showed good results in terms of clinical outcome, restoring knee varus and rotational stability 13 . Important Tips: Patients with associated proximal tibiofibular joint instability will benefit from this reconstruction because this technique will add stability to the joint.This surgical approach is technically demanding, requiring proficiency with surgical dissection.Damage to the common peroneal nerve can potentially occur. Careful dissection and placement of retractors should be observed.Risks include surgical failure due to unrecognized malalignment; especially in chronic cases, the patient should have a complete evaluation of the standing alignment and tibial slope 12 . Acronyms and Abbreviations: FCL = fibular collateral ligamentPFL = popliteofibular ligamentPLC = posterolateral cornerIT = iliotibialIKDC = International Knee Documentation CommitteeACL = anterior cruciate ligamentPCL = posterior cruciate ligamentPEEK = polyetheretherketonePROM = passive range of motion

Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears With Suture Augmentation

Background: Historically, the midterm outcomes of open anterior cruciate ligament (ACL) repair were rather disappointing, and ACL reconstruction subsequently became the surgical standard for ACL injuries. Recent studies, however, have shown that there might be a role for arthroscopic primary repair in appropriately selected patients with proximal ACL tears. Indications: Due to more prominent blood supply in the proximal ligament region, ACL repair should only be performed in patients with proximal tears and good-to-excellent tissue quality. Although all patients are potential candidates, this procedure is preferably performed acutely and in adult patients. Technique Description: First, it is identified whether a proximal tear with good tissue quality is present. Then, both ACL bundles are sutured individually from distal to proximal using a Bunnell-type pattern and a self-retrieving suture passer. The posterolateral bundle is then reattached first in anatomical fashion, using a 4.75-mm vented biocomposite suture anchor. Next, the suture anchor of the anteromedial bundle is preloaded with an internal suture tape augmentation. After anchor deployment, the suture tape augmentation is channeled through a small 2.5-mm tibial tunnel in the anterior third of the tibial ACL footprint. Finally, the suture augmentation is tensioned near full extension and fixed to the tibia’s anteromedial cortex using single suture anchor fixation. Results: Recently, we have published a series of the first 113 consecutive repair patients with minimum 2-year follow-up, of which 60 received additional suture augmentation. In this cohort, the overall failure rate was 13%, which was similar to 3 other studies on modern-day ACL repair (range: 5%-15%). Subgroup analysis showed that the failure rate was much higher in patients ≤21 years (38%) but low in patients >21 years (0%). Finally, it has been shown that there is an earlier return of knee motion, complications are rare, and there is less joint awareness after ACL repair as compared with ACL reconstruction. Conclusion: Selective, modern-day, arthroscopic primary ACL repair with suture augmentation seems to be a good alternative to ACL reconstruction in carefully selected patients, which include patients with proximal tears and good tissue quality and aged ≥22 years.

Rhinoplasty Dissection Planes (Subcutaneous, Sub-SMAS, Supra-perichondral, and Sub-perichondral) and Soft Tissues Management.

Rhinoplasty as an operation is akin to a game of chess, where every maneuver will influence the eventual outcome. Undoubtedly, more than one approach to the nasal soft tissues envelop can produce beautiful and safe results as will be described in the paper namely, the subcutaneous, sub-superficial musculoaponeurotic system, supra- and sub-perichondral planes. For different justifiable reasons surgeons have their preferences, regarding dissection planes on the tip, middle and upper thirds, and regarding the manipulation of the soft tissue layers and nasal ligaments. The concept of the nasal layers and the presence of relevant ligamentous structures and how to restore them in an anatomical fashion, will help to understand the logic behind various approaches.

919 Outcomes of Endoscopic Ultrasound Directed Trans-Gastric ERCP (EDGE): A Single Center Experience

INTRODUCTION: ERCP can be difficult in patients with Roux-En-Y foregut anatomy due to difficulty accessing the papilla, where balloon-assisted enteroscopy or laparoscopy based access has been used. Endoscopic ultrasound directed trans-gastric ERCP (EDGE) allows access to the excluded stomach via a lumen apposing metal stent (LAMS) from the gastric pouch, and passage of the duodenoscope in standard anatomical fashion. Early studies demonstrated high technical and clinical success rates of EDGE with few major adverse events (AEs). We aimed at describing rates of technical and clinical success and AEs of EDGE, impact on patients’ weight and incidence of persistent gastro-gastric fistulae (GGF). METHODS: This is a single center retrospective analysis of a prospectively collected database. All patients who underwent EDGE from 06/2018 to 05/2019 were included. AEs were defined per ASGE lexicon. Descriptive statistical analysis was used to assess outcomes. RESULTS: Nineteen patients were included in the study [mean age 59.4 years (SD = 10.7); 79% females, Table 1]. Two additional patients with spontaneous GGF noted at planned EDGE had no LAMS placed and were excluded. Choledocholithiasis was the most common indication (7/19, 37%), with three associated with cholangitis. Technical success for EUS guided LAMS placement/GGF creation was 100% (Hot AXIOS, 15 mm × 10 mm) with a mean procedure time of 26.8 (SD = 10) minutes and no major AEs. Same session ERCP was done in 2/19 (10%) with LAMS anchoring and 17/29 ERCPs (90%) performed a mean 5.5 (SD = 4.9) days after LAMS placement with a diagnostic duodenoscope (18/19, 95%) most commonly used. Mean ERCP time was 38.7 (SD = 4.9) min with a technical and clinical success of 95% (18/19). Two ERCP-related moderate adverse events occurred managed endoscopically and conservatively. LAMS were removed within 4 weeks of last ERCP, with APC +/- endoscopic suturing in 13/16 (81%) with 100% technical success of endoscopic closure. There was no weight gain noted on a mean follow up of 11.3(SD = 9) weeks. GGF resolution was confirmed in 5/16 with CT (1/5), Upper GI Series (2/5) or upper endoscopy (2/5) done in 6 months of GGF closure with other patients yet to reach the 6-month time-frame (Table 2). CONCLUSION: EDGE is an effective procedure for patients with Roux-en-Y foregut anatomy, with acceptable safety profile and low risk of persistent GGF or weight gain in this series. Further prospective studies are needed to assess the long-term safety, in regards to weight gain and persistence of GGF.

Detection of lymph node metastases in penile cancer.

Penile cancer (PC) is a relatively rare malignancy in the United States (US) but a greater concern in developing nations. Lymph node imaging remains critical to the staging and treatment of this disease as metastases develop in a predictable, anatomic fashion. Early surgical intervention remains a mainstay in treatment and imaging often aids in decision making. This review highlights the indications for imaging in both low-stage and advanced disease. Furthermore, we discuss the benefits and limitations of currently available imaging for staging of inguinal and pelvic lymph nodes in PC and novel modalities in development.

Aortic Arch Advancement and Ascending Sliding Arch Aortoplasty for Repair of Complex Primary and Recurrent Aortic Arch Obstruction.

The optimal treatment of patients with complex coarctation of the aorta and hypoplastic aortic arch is controversial. Children undergoing repair of obstructive arch lesions are at lifelong risk of recurrence. Multiple techniques have been described to address complex primary and recurrent coarctation. Our approach at Texas Children's Hospital (Houston, TX) has been to address these lesions in an anatomic fashion via median sternotomy, under cardiopulmonary bypass using the techniques of aortic arch advancement and ascending sliding arch aortoplasty. Anatomic repair of complex primary or recurrent aortic obstruction is safe and produces a favorable repair with a low rate of recurrence. Both operations restore normal arch contour using native aortic tissue. The decision of which particular surgical strategy to use depends on the patient's age, anatomy, and the elasticity of the tissue.

CorMatrix valved conduit in a porcine model: long-term remodelling and biomechanical characterization.

Porcine small intestinal submucosa extracellular matrix (CorMatrix; CorMatrix Cardiovascular, Rosewell, GA) is a relatively novel tissue substitute used in cardiovascular applications. We investigated the biological reaction and remodelling of CorMatrix as a tri-leaflet valved conduit in a pig model. We hypothesized that CorMatrix maintains a durable architecture as a valved conduit and remodels to resemble surrounding tissues. We fashioned the valved conduit using a 7 × 10 cm 4-ply CorMatrix sheet and placed it in the thoracic aorta of seven landrace pigs for 3, 4, 5 and 6 months. Biodegradation, replacement by native tissue, strength and durability were examined by histology, immunohistochemistry and mechanical testing. Four pigs, one per time frame, completed the study. The conduit lost its original architecture as a tri-leaflet valve due to cusp immobility, subsequent attachment to the wall segment and consequent maintenance of a thick arterial wall-like structure. Scaffold resorption was incomplete, with disorganized inconsistent spatial and temporal degradation even at 6 months. Fibrosis, scarring and calcification started at 4 months and chronic inflammation persisted. The partially remodelled scaffold did not resemble the aortic wall, suggesting impaired remodelling. Mechanical testing showed progressive weakening of the tissues over time, which were liable to breakage. CorMatrix is biodegradable; however, it failed to remodel in a structured and anatomical fashion in an arterial environment. Progressive mechanical and remodelling failure in this scenario might be explained by the complexity of the conduit design and the host's chronic inflammatory response, leading to early fibrosis and calcification.

Biomechanical Comparison of Acute Hill-Sachs Reduction and Remplissage to Treat Complex Anterior Instability

Objectives:Acute Hill-Sachs (HS) reduction represents a potential alternative method to remplissage for the treatment of an engaging HS lesion. The purpose of this study is to biomechanically compare the stabilizing effects of an acute HS reduction technique and remplissage in a complex instability model.Methods:This was a comparative cadaveric study of 6 shoulders. For the acute HS lesion, a unique model was used to create a 30% defect, compressing the subchondral bone while preserving the articular surface in a more anatomic fashion. In addition, a 15% glenoid defect was made in all specimens. The HS lesion was reduced through a lateral cortical window with a bone tamp, and the subchondral void was filled with Quickset (Arthrex) bone cement to prevent plastic deformation. Five scenarios were tested; intact specimen, bipolar lesion, Bankart repair, remplissage with Bankart repair and HS reduction technique with Bankart repair. Translation, kinematics and dislocation events were recorded.Results:For all 6 specimens no dislocations occurred after either remplissage or the reduction technique. At 90 degrees of abduction and external rotation (ABER), anterior-inferior translation was 11.1 mm (SD 0.9) for the bipolar lesion. This was significantly reduced following both remplissage (5.1±0.7 mm; p<0.001) and HS reduction (4.4 ±0.3 mm; p<0.001). For anterior-inferior translation there was no significant difference in translation between the reduction technique and remplissage (p=0.91). At 90 degrees of ABER, the intact specimens average joint stiffness was 7.0 ±1.0N/mm, which was not significantly different from the remplissage (7.8±0.9 N/mm; p=0.9) and reduction technique (9.1±0.6 N/mm; p=0.50). Compared with an isolated Bankart repair, the average external rotation loss after also performing a remplissage procedure was 4.3 ±3.5 deg (p=0.65), while average ER loss following HS reduction was 1.1 ±3.3 deg (p=0.99). There was no significant difference in external rotation between remplissage and the reduction technique (p=0.83).Conclusion:Similar joint stability was conferred following both procedures, though remplissage had 3.2-degree loss of ER in comparison. While not statistically significant, even slight ER loss may be clinically detrimental in overhead athletes. Overall, the acute reduction technique is a more anatomic alternative to the remplissage procedure with similar ability to prevent dislocation in a biomechanical model, making it a viable treatment option for engaging Hill-Sachs lesions.

Biomechanical Comparison of a Hill-Sachs Reduction Technique and Remplissage: The Potential Benefits of Anatomic Reconstruction

Biomechanical Comparison of a Hill-Sachs Reduction Technique and Remplissage: The Potential Benefits of Anatomic Reconstruction

Double-loop Anatomic Acromioclavicular Reconstruction

Acromioclavicular (AC) reconstruction surgery is per- formed to address high-grade AC separations. In the double-loop anatomic reconstruction, the coracoclavicular ligaments are recon- structed in an anatomic fashion similar to the technique described by Mazzocca and colleagues using a free tissue graft and tunnels through the clavicle. However, the double-loop technique passes a graft both through and around the clavicle using semitendinosus graft. This allows maximal use of the long hamstring graft. A preliminary case series of 7 patients (7 operations) is presented. Shoulder complications were observed in 0 patients who underwent double-loop anatomic acromioclavicular reconstruction. Temporary hamstring graft harvest site pain observed in 2 patients. The described technique is safe and potentially useful alternative method for AC reconstruction.

Turning the flesh inside-out: Uncovering the muscles and showing the veins in Jean Paul Gaultier’s scene costume Flayed

Abstract This article studies the use of anatomical motifs in fashion on example of Jean Paul Gaultier’s musculature bodysuit Flayed. Through a visual and tactile analysis of the garment and further contextualization in the light of anatomical imagery created since the Renaissance times, the author intends to find the meaning for showing the inner anatomy on the outside of the body. Previous research in the area of fashion and body considered mostly the way the image of the body can change by applying clothing. Is the anatomical fashion working of the image of the body in different ways than common clothing?

Anatomic Mapping for Surgical Reconstruction of the Proximal Tibiofibular Ligaments

Injury to the proximal tibiofibular joint is uncommon. Previous studies regarding the anatomy of this region have predominantly focused on joint orientation. As radiographic technology has advanced, later studies have attempted to evaluate the capsular anatomy. However, no reports specifically map the ligaments to this joint. The objectives of the current study were to define specific ligamentous structures that provide stability to the proximal tibiofibular joint, describe easily identifiable and reproducible surgical landmarks to aid in surgical reconstruction, and add to the understanding of the posterolateral structures of the knee previously described by other authors. The proximal tibiofibular joint ligaments were identified in 10 fresh-frozen cadaveric specimens. Average ligament length, width, and thickness and area of the footprints of the tibial and fibular attachments were measured. Distances from the ligament footprints to known anatomic landmarks (eg, Gerdy's tubercle, tibial articular surface, and fibular styloid) were also measured. The anterior ligament tibial attachment was a mean of 15.6 mm lateral and posterior to Gerdy's tubercle and 17.3 mm anterior and inferior from the fibular styloid. Posterior ligament tibial insertion was a mean of 15.7 mm inferior to the tibial articular surface on the tibial side and 14.2 mm medial and slightly inferior from the fibular styloid. Definable ligaments provide stability to the proximal tibiofibular joint and can be reconstructed in an anatomic fashion using the landmarks and parameters described. This information allows for an anatomic reconstruction of the proximal tibiofibular joint, which should provide patients with better outcomes and fewer postoperative sequelae.

Indications and contraindications for double-bundle ACL reconstruction

Over recent years, double-bundle reconstruction has gained popularity after studies showed significant advantages of adding a second bundle with regard to outcomes and biomechanics; in particular, it resulted in less rotational instability than after reconstruction with a traditional single-bundle technique. As the focus shifted further towards the restoration of the native anatomy, both single-bundle and double-bundle ACL reconstruction were performed in an anatomical fashion and yielded similar results. To date, no consensus has developed as to whether double-bundle reconstruction is better than single-bundle reconstruction or vice versa. However, after surgeons started to individualise their surgical approach to the patient, it has been found that both the anatomical single- and double-bundle techniques have their own set of indications and contraindications. Reconstruction of the ligament should focus on restoration of the native functional and anatomical properties and should take the size, shape and orientation of the ACL into account. When indications and contraindications for the technique used are based on native anatomical characteristics, either a single-bundle or a double-bundle procedure can be performed according to the same double-bundle concept.

Dynamic Definition Lipoabdominoplasty

INTRODUCTION: Lipectomy was first mentioned in 1899 and several technique innovations have been documented since then as the perfect procedure to provide skin removal in specific cases1,2. Liposuction is one of the new adjuvant procedures for abdominoplasty. Although results became reproducible and aesthetically pleasant, stigmata of lipectomy like the scarred navel and the “stretched” look of the flap skin are relevant to produce unnatural results. OBJECTIVE: The author describes Dynamic Definition Full Lipoabdominoplasty as a new reproducible technique, with a three-dimensional approach, based on High Definition liposculpture premises3, to enhance the areas of liposuction and take away the visual stigmata of the procedure. METHODS: From January 2005 to January 2012, a total of 147 consecutive procedures were performed. Ages ranged from 24 to 67 (x=42). Liposculpture was the first phase by dynamic (360-degree and multilayered) definition of the desired areas in an anatomical fashion. Also selective fat grafting in the gluteal area was performed. Lipectomy (second phase) was performed by flap tunneling technique and plication of the rectus abdominis m. Flap advance and closure were carefully and anatomically achieved. Follow up was accomplished within 24 and 48 hours, one, three, six and twelve months after surgery. Umbilicoplasty was selectively done after 8 to 60 days after the procedure in most cases. RESULTS: Most patients were satisfied with the results (93%). Major complication (1) was reported as wound border suffer, solved with early carboxiterapy, no secondary surgery was needed. Minor complications as bruising and seroma were highly reported (60%), most of them occurred after drain removal. No flap necrosis was reported in our series of cases. CONCLUSION: Dynamic Definition Tummy tuck is a reproducible technique in abdominoplasty, aesthetically pleasant results can be achieved while an athletic contour gives a more natural result, successfully taking away the “lipectomy” appearance.Figure 1: A 44-year old woman. Preoperative photo. Notice the excess fat and the redundant skin in the abdomen.Figure 2: A 44-year old woman. Postoperative photo. Notice the new athletic and slimmer appearance. The normal women underwear can dissimulate the scar.

Dynamic-Definition Male Pectoral Reshaping and Enhancement in Slim, Athletic, Obese, and Gynecomastic Patients Through Selective Fat Removal and Grafting

One of the most appealing characteristics of an athletic male body is a well-defined pectoral area. For decades, implants have been the gold standard method for the treatment of this area, but it is not suitable for every case. The goal was to design a mixed technique combining autologous fat extraction and grafting in an anatomically guided fashion to produce a highly athletic contour in the male pectoral. The patient criteria included a body mass index (BMI) lower than 30 kg/m(2), adequate skin tone, and general good health. A three-phase procedure was performed, beginning with infiltration of tumescent solution and followed by fragmentation of extra fat in an anatomic fashion using internal third-generation ultrasound; extraction that blends deep, intermediate, and superficial fat removal; and multilayer fat grafting in the pectoral area. In the presence of gynecomastia, a selective pull-through technique was used in an anatomic manner. In a series of 154 consecutive male patients, the minor complications (n = 15) included asymmetries (n = 10) and residual gynecomastia (n = 5). The major complications (n = 3) included unilateral hematoma (n = 2), and abscess that required sonographic-guided removal (n = 1). An appealing muscular contour was produced in most patients, and the satisfaction rate was very high. Implants are no longer the only option for defining and augmenting the male chest. Combining fat grafting in a multilayer fashion with precise anatomic fat and gland removal achieved a contoured and athletic male pectoral in a safe and reproducible manner. This journal requires that authors assign a level of evidence to each article.

Results of Anatomic Approach to ACL Revision Surgery (SS-71)

Many studies have shown that anatomic ACL reconstruction better restore knee kinematics close to a native condition as compared to the traditional non-anatomic reconstruction.. This paper provides the ACL surgeon with solutions to revise failed ACL reconstructions in an anatomic fashion utilizing the anatomic primary reconstruction concept in revision cases.

Physical Examination of the Athlete’s Elbow

Elbow injury is encountered less frequently than are other joint conditions. The bony architecture, muscle, ligament, and nerve anatomy are complex, and the forces leading to injury in the athlete’s elbow are unique. Appreciating the pathomechanics leading to injury and a detailed knowledge of elbow anatomy are the foundation for conducting a directed history and physical examination that achieves an accurate diagnosis. Recent advances in physical examination have improved our ability to accurately diagnose and treat athletic elbow disorders. This article reviews general and focused physical examination maneuvers of the elbow in a systematic anatomic fashion.

Anatomic Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction, Part 2

The anterior cruciate ligament has been and is of great interest to scientists and orthopaedic surgeons worldwide. Anterior cruciate ligament reconstruction was initially performed using an open approach. When the approach changed from open to arthroscopic reconstruction, a 2- and, later, 1-incision technique was applied. With time, researchers found that traditional arthroscopic single-bundle reconstruction did not fully restore rotational stability of the knee joint and a more anatomic approach to reconstruct the anterior cruciate ligament has been proposed. Anatomic anterior cruciate ligament reconstruction intends to replicate normal anatomy, restore normal kinematics, and protect long-term knee health. Although double-bundle anterior cruciate ligament reconstruction has been shown to result in better rotational stability in both biomechanical and clinical studies, it is vital to differentiate between anatomic and double-bundle anterior cruciate ligament reconstruction. The latter is merely a step closer to reproducing the native anatomy of the anterior cruciate ligament; however, it can still be done nonanatomically. To evaluate the potential benefits of reconstructing the anterior cruciate ligament in an anatomic fashion, accurate, precise, and reliable outcome measures are needed. These include, for example, T2 magnetic resonance imaging mapping of cartilage and quantification of graft healing on magnetic resonance imaging. Furthermore, there is a need for a consensus on which patient-reported outcome measures should be used to facilitate homogeneous reporting of outcomes.

Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: A review of 17 consecutive cases over 2 years

Background The conflict between the anatomist and biologist surgeons is exemplified by the debate about subtrochanteric hip fractures. Closed intramedullary nailing is biologically friendly but may result in prolonged procedures and malunion. By contrast, accurate anatomical open reduction may disturb the biological composition of the fracture environment. Methods There were 17 patients at our institution over a 2-year period whose long oblique subtrochanteric fractures would not reduce perfectly in an anatomical fashion using closed methods. All these patients had their fractures treated identically using a new policy at our unit. This strategy involved reduction of the fracture through an open approach, and then employing cerclage cables to stabilise the fracture in an anatomical position before finally inserting a cephalomedullary nail. These patients were retrospectively reviewed at an average of 18 months postoperatively, to assess their progressive functional and radiological outcome up to that point. Results One patient had nonunion and required a secondary procedure. One patient died 8 days postoperatively from a medical complication. The remaining 15 healed within 6 months and all returned to independent living. Conclusions The results demonstrate that judicious use of cerclage cables to augment fixation of subtrochanteric femur fractures does not have a deleterious effect on healing. One should endeavour, however, to minimise the number of cables used. The basic science literature underpinning our approach to these unstable fractures is also discussed.